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Discharge Planning


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Discharge Planning
 


What is it and how can it help me?

Planning for discharge with clear dates and times reduces:

  • Patient's length of stay
  • Emergency readmissions
  • Pressure on hospital beds

This is true for all patients, both day surgery and patients who have more complex needs.

When does it work best?

With elective care, discharge planning should start before admission. This allows everyone to focus on a clear endpoint in the patient's care. It also reduces errors and unnecessary delays along the patient pathway.

If inpatient beds are a bottleneck, reducing pressure on beds will increase throughput and therefore reduce referral to treatment times.

How to use it

There are some common key elements when planning for discharge, regardless of whether a patient is receiving emergency or elective (inpatient or day case) care. These are:

  • Specifying a date and / or time of discharge as early as possible
  • Identifying whether a patient has simple (80 per cent of all patients) or complex discharge planning needs
  • Identifying what these needs are and how they will be met
  • Deciding the identifiable clinical criteria that the patient must meet for discharge 

Discharge.jpg

 

 

 


 

 

 

 

 


 

This guide focuses on the key elements of planning for elective discharge for simple discharges. (The approach is similar for day case and simple inpatient discharge.) This includes a summary outlining the approach for complex discharge plus the resource materials available. There is also a short description to help discharge planning following an emergency admission.

Simple discharge (inpatient / day case)

    1. Plan the date and time of discharge early

Plan discharge at pre-operative assessment so that everyone, including patients and carers, know what needs to happen and when the patient will be discharged. It also means patients/carers know what arrangements they need to make to help the patient get back home.

'To achieve a high quality service, discharge planning in day surgery should begin before the adult or child is admitted to the unit.'   Royal College of Nursing (discharge planning for day surgery).

    2. Plan for patients to be discharged before the peak in admissions

As with hotels, many hospitals find planning for a reasonable proportion of patients to leave the ward before 11.00 am helps to manage the total loading on beds. The impact of this is illustrated in the ‘background' section.

    3. Plan for discharge seven days per week

Admission patterns often loosely follow the day of the week. This is also true of discharges, with a rush on Friday to clear beds for the weekends. However, few discharges actually take place over the weekend. This can cause problems, especially on Monday when there may be many admissions for inpatient elective care. A focus on ‘planning for discharge' seven days a week helps to reduce bed pressures. This is also illustrated in the 'background' section.

    4. Patients are discharged using a criteria based process

               There is a range of discharge planning tools and guidance available.
 
  • British Association of Day Surgery, 2002 ‘Ready to go Home' (Discharge criteria: guidelines about the discharge process and the assessment of fitness for discharge).
    Discharge planning: day surgery information by the Royal College of Nursing. A framework that covers physical, psychological and social aspects of patient care. You can use it to develop guidelines for patient discharge following day surgery.
    5. Co-ordinate and check everything is in place 48 hours before discharge to ensure that everything is ready

This includes checking  'take home' medications and transport (including transport being provided by family / friends). For longer stays of over 48 hours, the discharge planning checklist should be completed 48 hours prior to discharge.

    6. Timely and accurate communication for discharge

Discharge for patients with more complex needs

About 20 per cent of patients have more complex needs and may need additional input from other professionals such as social workers, therapists etc. The involvement of additional people makes co-ordination and planning even more critical.

Planning at the pre-operative stage or early on following admission will really help to reduce delays. Further information about discharge planning is available from the Health and Social Care Agent Team: 

Discharge following an emergency admission
The same evidence applies for all discharges regardless of type of admission so planning for discharge should begin as early as possible following an emergency admission.

Examples

'Criteria based discharge has allowed our nursing staff to be absolutely clear about what patients have to do before they go home, and this has got rid of the fear of discharging Mr X's(consultant) patients without his say so.'

Examples of criteria for discharge used in well performing services for hip and knee replacement surgery include:

  • Independence in washing, dressing and mobility
  • Safe negotiation of stairs if necessary
  • A clean wound
  • Eating and drinking
  • Postoperative x-ray performed

'Delivering Quality and Value', NHS Institute for Innovation and Improvement

Making plans to go home

'A day and time for your discharge home will be agreed in advance with you. This will allow you to plan ahead for your own discharge. The ward staff may indicate that you should be collected and accompanied by a friend or relative when you go home. It is important that you plan this with your friends or relatives as soon as you know your discharge date.

When you leave we will give you a limited supply of any medicines you may need and a discharge letter for you to take to your GP when you get home.

Please leave your home address and contact number with a member of staff on the ward. If you are planning to stay somewhere else, please leave an address where you can be contacted.'

Nuffield Orthopaedic Centre NHS Trust, patient information.

What next?

If bed constraints are a hospital wide problem, carry out a simple hourly flow diagnostic to look at patterns of admission and discharge.

Additional resources

Complex discharge: more information available from the Health and Social Care Change Agent Team including a range of case studies.

British Association of Day Surgery, 2002 ‘Ready to go Home' (Discharge criteria: guidelines about the discharge process and the assessment of fitness for discharge).

A Positive Outlook: Good practice toolkit
This toolkit provides best practice guidance to show what works in reducing the current levels of delayed discharge being experienced by adults and older people in mental health services. It focuses on the practical steps which can be taken to improve discharge.

Background

The emphasis on discharge planning really began as a focus on the few patients who stay in hospital for a long time after they are clinically ready for discharge (termed as ‘bed blockers').

Discharge planning is a key part of the operational management of beds
There is evidence that there have been, and still are, temporary mismatches in the demand and capacity of beds. This occurs when the total number of new admissions necessitates patient discharge so that their beds become available. The Emergency Services Collaborative identified this as one of the reasons why A&E departments fill. The hospital is, to all intents and purposes, ‘gridlocked' until patients are discharged. The Department of Health developed the following illustration in its publication 'Achieving timely simple discharge from hospital; a toolkit for the multidisciplinary team'.

'The dotted line shows the extra beds needed in this hospital during the few hours when admissions outpaced discharges. The red line shows that moving even just 30 per cent of discharges ahead of admissions would reduce the maximum bed requirement from 35 to a very short term peak of just 10 over the average required.'
 
Therefore, planning discharges before the peak in admissions is an effective way to smooth the total demand for beds.
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The same authors also illustrate the importance of continuous discharge throughout the week to reduce the variation in demand for beds.
 
'Many hospitals still try to manage weekend capacity by discharging large numbers of patients on a Friday. Discharges then slow to a trickle until Monday morning (or often Monday afternoon). This is not the most effective strategy. It often takes several days for the mismatch between admissions and discharges, built up over the weekend, to resolve, with predictable consequences in terms of pressure on beds. The example below shows this.'
Discharge 3.jpg

 

 

 

 

 

 

 

 

 

 

Good Bed Managment

Evidence of the impact of discharge planning:
The impact of discharge planning on readmission rates, length of stay, health outcomes and cost to patients and healthcare providers is uncertain. The authors found it difficult to assess the impact of the evidence and concluded that, although the impact of discharge planning may be slight, it is possible that even a small reduction in length of stay or readmission rate could free up capacity for subsequent admissions in a healthcare system where there is a shortage of acute hospital beds.

Discharge planning from hospital to home.

Acknowledgements / sources

Department of Health
British Association of Day Surgery
'Delivering Quality and Value', NHS Institute for Innovation and Improvement

© Copyright NHS Institute for Innovation and Improvement 2008